IN THE NAME OF GOD

#BURNS

BURNS INCIDENCE Approx. 140 Burn Centers in U. S. Approx. 1.25 million people suffer a

burn injury in the U.S. each year. About 5,500 people die from burns and

related inhalation injuries annually Young people and elderly are high risks Most injuries occur at home 75% of patients are victims of their own

actions

Burns Devastating Heals slowly Disfiguring Long months of

rehabilitation Occupational

therapy

Nurse’s role: Be knowledgeable

of the pathophysiology of burns

Help meet biopsychosocial needs

Carry out measures to meet physical needs

Phases of Burn Care Emergent/Resuscitative Phase (onset of injury

to completion of fluid resuscitation) On the scene care (ABC, initial wound care,

injury) Management of fluid loss & shock

Acute/intermediate Phase (beg. of diuresis to near completion of wound closure) Maintenance of resp. & circulatory status, fluid &

electrolyte balance, GI function Infection prevention, wound care, pain

management, nutritional support Rehabilitation Phase (wound closure to optimal

level) Wound healing, restoring maximal functional

activity, alterations in self-image & lifestyle

Burns Emergency management

cold wet towels, cool water, no direct ice, cover with sterile dressing

don’t break blisters lotion only after a burn is completely cooled wrap loosely to avoid putting pressure on burned

skin ABC Prevent shock Fluid replacement Flush area thoroughly with water or saline

(chemical burns)

Burns Short term effects of burns

fl volume deficit hypovolemic shock infection

Long term effects of burns scarring (full thickness burns) contraction

Burns Minor burns

<15% TBSA with <2% full thickness

Moderate burns partial thickness burns 15-25% TBSA

with 2-10% full thickness

Burns Major Burns

>25% TBSA or >10% full thickness involvement of hands, feet, face or genitalia

Survival due to refinement of fluid resuscitation management and early transfer to burn unit.

Burns Facial burns have the possibility of

airway impairment Important to know the

circumstance of burn:greater risk of airway involvement if burn occurred in closed space

Always suspect a head injury if a patient had an electrical burn which resulted from a fall

Mechanism of Burn Injuries

flame (thermal) 55% contact with fire etc. (smoke inhalation can be as

damaging as thermal) get pt. Supine to decrease facial burn

(STOP, DROP, ROLL) prolonged exposure to cold

considered thermal burn

Mechanism of Burn Injuries

Scald 33% most common for children

chemical 10% severity depends on duration of contact,

conc. Strength of chemical, amt. Of tissue exposed

alkaline more serious than acid irrigate area immediately (most chem labs

have high pressure showers) powder-brush off; do not inhale

Mechanism of Burn Injuries

chemical con’t chemical burns destroy tissue through

protein coagulation rather than heat some acids (sulfuric and muriatic) also

destroy tissue through heat production in chemical reaction with tissue

first aid take of clothes (chemical on clothes)

Mechanisms of Burn Injuries

First aid of Chemical con’t if powder, dust off before irrigate so not attempt to neutralize agent (takes

valuable time) running water will dilute the chemical

Electrical <10% voltage running through body can do a lot

of damage (leaves an exit wound as well as entrance wound); evaluate internal damage along the path of the current

Mechanisms of Burn Injuries

Electrical con’t as electrical current goes through

tissue, it produces heat causing thermal coagulation necrosis

immediate extent of injury unknown (electrical current pathway)

deep muscle burn-burgundy color urine

Classification of Burns Burn injuries are

described according to: Depth of injury Extent of body

surface area (BSA) injured

Depth Superficial Partial-

thickness Deep partial-thickness Full-thickness

BSA Rule of nines Lund & Bowder

method Palm method

Classification of Burns First degree (superficial partial-

thickness) eg. Sunburn involvement: usually epidermis only symptoms: tingling, hypersthesia (inc.

sensitivity to pain), skin reddened,blanched with pressure, minimal or no edema

how it heals: some peeling over a week, no scar

Types of Burns Second degree burn (partial-

thickness) eg. Scalding burns involvement:epidermis and part of dermis symptoms: hyperesthesia, sensitivity to

cold, blistered mottled red base, broken epidermis , weeping surface

how it heals: new epidermis grows in 1-3 weeks

Types of Burns Third degree (full thickness)

eg. Fire burn, prolonged exposure to hot liquid involvement: epidermis, entire dermis, and

sometimes subcutaneous tissue, muscle, and bone

symptoms: painless, s/s shock, hematuria, hemolysis of blood likely,skin and fat exposed edema, skin (dry, pale white, or charred)

how it heals: needs skin grafting unless very small

Burns Rules of nine (total equals 100%)

arms 9 each (4 1/2 front, 4 1/2 back) legs 18 each (9 front, 9 back) trunk 36 (front 18 and back 18) head and neck 9 (41/2 front, 4 1/2 back) perineum 1

A superficial burn can bring on a severe systemic reaction when it covers a large body surface area

Burns Suspect inhalation injury if victim

has burns on head, neck, or anterior chest

s/s inhalation injury dyspnea, carbonaceous sputum,

wheezing. Hoarseness (caused by laryngeal edema), altered mentation

Burns Pain

continuous problem with second-degree burns but not third degree because nerves have not completely been destroyed as with third degree

when eschar removed from third degree, other pain mechanisms become operative

Burns Assessing a patient with burns

ABCs history and physical, rules of

nine,pulmonary status,check peripheral pulses on burned extremities,vital signs, urine output, labs fluid replacement, prevention of infection, psychological needs

temp usually hypothermic

Physiologic Changes con’t

Pulmonary carbon monoxide most common

cause of inhalation injury because it is a byproduct of the combustion of organic materials and therefore present in smoke (need 100% O2 due to cell hypoxia

upper airway injury, pulmonary edema, etc

Physiologic Changes in Burn Injury

Cardiovascular outpouring of catecholamines from SNS

(sympathetic nervous system) with injury which leads to peripheral blood vessel constriction and increase pulse rate

vessels become more permeable due to injury and allow fluid and colloids to leak into surrounding tissues (third spacing)

Physiologic Changes con’t

Cardiovascular peripheral vascular vasoconstriction

further decreases cardiac output with third spacing less intravascular

fluid which leads to low blood volume and low cardiac output which contributes to inadequate tissue perfusion

Physiologic Changes con’t

Renal decreased renal blood flow which

leads to glomerular damage GI

hypovolemia leads to gastric dilatation and paralytic ileus

Curling’s ulcer-stress ulcer

Physiologic Changes con’t

Fluid and Electrolytes hyponatremia (first week of acute

phase) as water shifts from interstitial to the vascular space

hyperkalemia (immediate after burn) results from massive cell destruction

hypokalemia may occur later with fluid shifts and inadequate potassium intake

Burns Pyschosocial

self-concept body image

There is a rapid fluid and electrolyte change taking place fluid loss leads to decreased blood volume

which leads to thicker blood and decreased efficiency of circulation. There is a inc cellular elements of blood which leads to inc Hct

Burns What happens in third spacing

burns produce a dilatation of capillaries and the small vessels in the area of the burn leading to increase capillary permeability. The plasma seeps out into the surrounding tissues which produce blisters and edema..

The capillary walls that are damaged permit plasma proteins to move into interstitial (extracellular) spaces

Burns Third spacing con’t

the developed capillary permeability allows plasma proteins to go through the barrier.

There is decreased osmotic pressure in blood vessels and increased osmotic pressure in interstitial space and fluid accumulates at the burn sites in blister leading to third spacing loss. Fluid shift is from vascular compartment to third space.

Burns Fluid loss with burns great. Fluid

loss by evaporation 20 times greater than normal. Loss due to evaporation called white bleeding.

Burns First 24-48 hours

large amounts of Na+ move with fluid from intravascular (within vessels) to interstitial fluid (Normally Na+ present approximately in same proportions both in intravascular and interstitial areas)

Increase in release of aldosterone and antidiuretic hormone as a result of general stress response (this inc amt of Na+ and H2O retained. Pt. Becomes oliguric.

Burns First 24-48 hours con’t

K+ elevated in blood since tissue destruction and oliguria (hyperkalemia)

Patients’ feet cold due to inc. BMR (body’s reaction to try to replace heat lost from evaporation)

Burns 48-72 hours

Na+ shifts back to intravascular space (capillaries begin to regain their integrity)

Diuresis leads to low K+ (hypokalemia) RBC loss from a microangiopathic anemia

(severeness depends on extent of burn) RBC destruction initially caused by heat of

the burn and later by hemolysis of heat damaged cells (result not only anemia but possible

Burns 48-72 hours con’t

kidney damage. Damaged RBC’s release Hgb which is filtered by kidneys.

Myoglobin is released by damaged muscle tissue. Both are filtered by kidneys and kidney tubules. They may get plugged which leads to acute tubule necrosis.

Diuresis phase lasts 3-5 days after burns. Vascular leakage recovery complete.

Burns Parkland/Baxter Formula

4 ml RL/kg body wt X % TBSA=ml RL for 24 hours

eg. Pt. wt=75 kg and burned 25%4/75/25=7500 ml/24 hours50% 1st 8 hours=3750ml25% 2nd 8 hours=1875 ml25% 3rd 8 hours=1875

Burns Parkland/Baxter Formula

eg. Pt. Wt 82kg body wt and burned 58%

4/82/58=19024 ml/24 hours50% 1st 8 hours=9512 ml25% 2nd 8 hours=4756 ml25% 3rd 8 hours=4756 ml

Usually D5 1/2 NS with KCL when pt in diuretic phase

Burns Goal: perfuse vital organs as fully

as possible without overload Nutrition

greater protein requirement due to negative nitrogen balance

2 times calories 2 times protein

Burns Full thickness burns result in death

of skin and subcutaneous tissue Compartment syndrome

pain, pallor, decreased capillary refill, decreased peripheral pulses, decreased sensation, impaired movement (Poor peripheral tissue perfusion)

Burns IV best route for pain relief (peripheral

vasoconstriction limits absorption of drug given IM or SQ route)

Open wound-use bed cradle Circumferential burns usually involve an

extremity edema may shut off circulation and an

escharotomy or fasciotomy may be necessary to

Burns relieve the constriction and return

normal blood flow Infection remains a threat until all

second degree burns have healed and third degree burns have been closed by grafting (second degree could become third degree if infection goes deeper)

Burns (Grafts) Graft-a piece of tissue separated

completely from its normal and original position and transferred by one or more stages to correct a distant defect

Free graft: completely separated from their donor site (blood supply completely interrupted) survival of graft depends on vascular bed

from recipient site

Burns (Grafts) Free flap graft (free-tissue transfer)

cover a variety of wounds, cover exposed tendons, bones, major blood vessels.

Completely severed from the body and transferred to another site

Pedicle graft a segment of tissue that has been left

attached at one end (pedicle) while other end has been

Burns (grafts) Pedicle graft (con’t)

moved to recipient area used when thick pieces of skin that

could not survive an interruption of blood supply are transplanted

usually about 3-4 weeks for sufficient blood supply to be established

Burns (grafts) Split thickness graft

varies from thin to nearly full thickness of skin

Full thickness graft composed of a full depth of

skin(epidermis and dermis) gives best cosmetic appearance so used for

face, neck, hands

Burns (grafts) Pre-op skin grafts

hgb and clotting time noted since their levels can affect healing process

tissues need to be free from infection pt in optimum physical condition pt teaching

Burns (grafts) Necessary for a graft to take

recipient bed must be adequately vascularized

graft must be in complete contact with the bed

immobilization must be assured area must be free from infection

Burns (grafts) Types of grafts

allografts (cadaver) temporary xenografts animal (pigskin) autografts (self)

split thickness-epidermis 8-12 thousandth of an inch thick

full thickness-full depth of skin sheet grafts are put on joint areas (areas

that stress) and secured with staples or sutures

Bone (grafts) Autografts (con’t)

mesh grafts-donor skin expand to cover large area expands graft 1 1/2 -9 times its original surface

culture epithelial growth medium-grows 50-70 times initial sample (donor site heals in 1-2 weeks)

Debridement Surgical (excise) Mechanical or enzymatic (commercial

preparation) natural (body and bacterial enzymes dissolve

eschar

“Cultured Skin” ref UCSD 2001

Growing cultured skin from samples taken from patients

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Burns (medications) Silver nitrate 0.5% (rarely used)

con’t wet dressing effectively prevents cross infection

>0.5% injures the tissue and not effective<0.5%

danger of electrolyte imbalance (especially Na and K) since the electrolytes are withdrawn from the body fluids and also from the dressing.

Turns black in sunlight and stains clothes and hands black

Burns (medications) Silvadene

wide-spectrum antimicrobial that is nonstaining and relatively painless

no systemic metabolic abnormalities however is contraindicated in pregnant women near term and premature infants

does not penetrate the eschar as well as sulfamylon

Burns (medications) Sulfamyalon acetate

interferes with bacterial cellular metabolism diffuses rapidly through burned skin and

eschar used for gram-negative organism burning sensation after applied topically may cause metabolic acidosis and is a

carbonic andryrase inhibitor may cause a rash

Burns (medications) Furacin-nitrofurazone (gauze or

cream) a synthetic broad-spectrum antibacterial inhibits enzymes required for

carbohydrate metabolism in bacteria

Xeroform-a fine mesh gauze with antimicrobial action

Case Study A 42-year old patient is brought to the ED

after being rescued from a house fire, where firefigthers found her unconscious in a bedroom closet. She has sustained burns to her right arm, right chest, and both lower extremities. On admission, she arouses to painful stimuli only. Her VS are BP 140/74, HR 112, RR 30/min and labored. She is afebrile. She has facial edema and visible soot in the oral pharynx and nares. Crackles are heard on auscultation, with decreased resp. excursion. Stridor is audible. The affected skin areas are white and inelastic, surrounded by heperemic, moist-looking tissue. She has pain on pinprick in the hyperemic tissue only.

Case Study cont. Lab results reveal a mildly

elevated glucose level, elevated Hg and Hct. Urine specific gravity of 1.030. Low PaO2 and an elevated carboxyhemoglobin level, at 37%.

What is your treatment plan? Nursing Diagnosis?

What to do about the pain during PT

U of W Harborview Burn Center is using VR (virtual reality) a non-pharmacological analgesic (distraction) used in addition to traditional levels of opioids

during wound care and physical therapy found VR worked much better than Nintendo64 pilot study showed dramatic drops in pain

during treatments

Why VR works for pain Pain perception is largely psychological pain requires conscious attention VR draws pt into another world (this

drains a lot of attentional resources leaving less attention available to process pain signals) in snow world for example the patient fly

through icy canyons etc (pts experience burning sensation during wound care so this game is designed to put out the fire)

NY Hospital-Cornell Medical Center Burn Center (1998 data)

5,000 outpatients seen/yr (>1,000 children)

1,300 inpatients seen/yr team approach(surgeons,nurses,

therapists, nutritionists, social workers)

mission develop an increasing effective

teaching and

NY Hospital-Cornell Medical Center Burn Center (1998 data)

NY’s mission con’t public awareness methods having the highest standards of clinical and

therapeutic excellence continued expansion of research in all

phases of thermal injury an optimum environment in which patients

may recover with the help and expertise of NY’s hospital-wide administrative, medical and paramedical specialists

UW Burn Center Approach to deep burn wounds

remove wound surgically within 1st post burn week

immediate grafts after wound removed to provide best functional and cosmetic results

Treatment for (TEN) Toxic Epidermal Necrolysis disease resulting from a drug reaction whereby the body’s entire epidermis sloughs

UW Burn Center treatment of TEN con’

use of pig skin and immaculate supportive care

mortality has been reduced from 70% to 15%

hospital stay has been reduced from months to average of 3 weeks

UCSD Burn Center 450 admits/year

Brave Heart Kids Program Activities Work on promoting self-esteem

Baltimore Regional Burn Center (John Hopkins)

1800/year outpatients Michael D. Hendrix Research Center

Died from burn and ARDS in 1995 Delta plane crash in Georgia

Family donated large amount of money to research Research

Infection prevention Wound healing New ways to culture skin Treatment of ARDS Immunologic response to burns

Prevention of Burn Injuries

Proper education and supervision childproof items in electrical sockets keep dangerous items (matches) out

of reach Safety measures for the elderly teach small children 911 smoke detectors in house STOP, DROP, AND ROLL